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Methods
The ORDET cohort was established in northern Italy between June 1987 and June
1992, when 10,786 healthy women, ages 35 to 69 years, were enrolled [20,21]. They were all
residents of the Varese province, an area covered by the Varese Cancer Registry [22], who
had heard about the study through the media, at public meetings, and at breast cancer early-
detection centers, and who volunteered to participate. At recruitment, a number of baseline
characteristics, including demographics and dietary intake, were queried from each
participant via questionnaire. Direct measurements of several anthropometric variables,
including height and weight, were conducted, and blood and urine specimens were collected.
Because of the focus of the study on endogenous hormones and their relation with breast
cancer risk, stringent inclusion criteria were established, and highly standardized conditions
on collecting biologic samples were applied. Women were excluded if they reported a
bilateral oophorectomy, were currently breast feeding or pregnant, used oral contraceptives or
hormone-replacement therapy in the last 3 months, were affected by chronic or acute liver
disease, or reported a history of cancer (with the exception of nonmelanoma skin cancer).
Information on cancer outcomes, which was available from the local cancer registry
(Varese Cancer Registry), was linked to the ORDET cohort to identify incident breast cancer
cases up to December 2003. The Varese Cancer Registry is of high quality: <2% of breast
cancer cases are known to the registry by death certificate only, and the histology and
cytology of 96.3% of all cases has been confirmed through pathology reports [20,23]. The
ORDET file was also linked to the Varese residents’ files to check participants’ vital status.
Participants were censored at the time of cancer diagnosis, death, or loss to follow-up,
whichever came first (median follow-up time, 15.4 years). Written consent was obtained
from all study participants, and the study was approved by the Ethical Review Board of the
National Cancer Institute of Milan (Italy).
Blood collection
A detailed description of blood-collection methods was provided previously [12,17].
In brief, blood samples were collected after overnight fasting between 7:30 AM and 9:00 AM
from each woman. They were timed to be collected between days 20 and 24 of their
menstrual cycle (that is, during the midluteal phase). For further verification of their luteal
phase during blood collection, women were given a postcard to report the date of the
subsequent bleeding after the blood drawing. Of 6,667 women who had at least one
menstruation in the 12 months before recruitment, 6,030 (90.4%) returned their postcard with
information on the date of the menses subsequent to the blood collection. Blood samples
were stored at -80°C until the present hormone determinations.
Laboratory methods
Stability and reliability of the ORDET collection method for sex steroids in
premenopausal women were previously described [12]. Blood samples from breast cancer
cases and related controls were handled identically and assayed together on the same day and
in the same run.
All samples were taken out of the freezer simultaneously and sent to the laboratory in
the same parcel on dry ice. Laboratory personnel were blinded to case-control status. Control
of analytic error was based on the inclusion of two standard samples. All samples were
assayed in duplicate, by using commercially available kits following the manufacturer’s
instructions. Plasma sex steroid measurements (testosterone, free testosterone, SHBG, and
estradiol) were conducted by Centro Medico Diagnostico Emilia (Bologna, Italy). For
testosterone and free testosterone, we used Coat-A-Count procedure, a solid-phase
radioimmunoassay (Diagnostic Products Corporation, Los Angeles, CA, USA); for SHGB,
IMMUNOLITE 1000 Analyzer, a solid-phase, chemiluminescent immunometric assay
(Diagnostic Products); and for estradiol, Orion Diagnostica SPECTRIA Estradiol Sensitive
RIA test, a coated-tube radioimmunoassay (Orion Diagnostica Oy, Espoo, Finland). Quality
control was done at three concentrations for SHBG and total and free testosterone and at four
concentrations for total estradiol. In each batch, quality-control samples were evaluated in
quadruplicate. Within-batch quality control coefficients of variation for high and low
concentrations were 5.9% and 14.0% for estradiol; 5.8% and 10.6% for total testosterone;
7.0% and 9.6% for free testosterone; and 3.1% and 3.4% for SHBG. Average between-batch
coefficients of variation for high and low concentrations were 7.4% and 16.4% for estradiol,
8.7% and 18.5% for total testosterone,14.9% and 17.2% for free testosterone, and 4.9% and
4.6% for SHBG. Serum levels of progesterone were compatible with ovulatory cycles,
ranging between 5.3 and 21.5 ng/ml in control subjects and between 4.8 and 20.8 ng/ml in
incident breast cancer cases.
Statistical analyses
Based on their distribution, we applied logarithmic transformations to the data for LH,
FSH, and SHBG, and square-root transformations to total testosterone, free testosterone,
progesterone, and estradiol. We evaluated differences between case and control means by
using the t test for paired data or the Wilcoxon signed test, as appropriate. Pearson partial
correlation coefficients, adjusted for age and case-control status, were computed to examine
the strength of linear associations among the various hormones and between each hormone,
the waist circumference, and the body mass index (BMI).
We used conditional regression models to estimate the relative risks of breast cancer
(reported as odds ratios (ORs) with 95% confidence intervals (CIs)) by tertiles of circulating
sex steroids, which were defined on the basis of the values for all control subjects. We used
likelihood ratio tests to assess linear trends in odds ratios, with increasing exposure level as a
continuous variable.
The effects of additional potential confounders (other than the matching criteria,
which were controlled by study design) were examined by including additional regression
terms into the logistic regression models. Potential confounders included age at recruitment,
BMI, because of its role in the hormone metabolism, education, and years of education.
Furthermore, the better to characterize the period of the ovarian cycle at blood drawing (12),
multivariate models were adjusted for variables related to the timing of the ovarian cycle at
blood drawing, such as time between date of last menses before blood sampling and day of
blood sampling, time between date of menses after blood sampling and date of blood
sampling, circulating FSH and LH levels, and menstrual-cycle length. We used STATA
version 8 for all analyses. All P values were two-sided.
Results
Study participants were all premenopausal, with an age range of 35 to 54 years at
blood collection. Most of the women’s baseline characteristics did not differ by casecontrol
status (Table 1), in particular, for the reproductive variables.
In Table 2 partial correlation coefficients, adjusted for case-control status and age at
blood donation, indicated that serum concentration of estradiol (E2) statistically significantly
correlated with all the other hormones, with correlation coefficients (r) ranging from 0.20
with progesterone to 0.38 with total testosterone. Also, the sex hormone-binding globulin
(SHBG) statistically significantly correlated with most of hormones, with the highest positive
correlation with estradiol (r = 0.32). We also observed that SHBG had significant negative
correlation with BMI (r = -0.25), waist-to-hip ratio (r = -0.21), FSH (r = -0.12), and free
testosterone (r = -0.22). Both total testosterone and free testosterone correlated with estradiol
(free testosterone, r = 0.22) and LH (r = 0.22 and r = 0.11 for total and free testosterone,
respectively). In addition, free testosterone correlated with BMI (r = 0.16). For all study
subjects combined, women who developed breast cancer had statistically significantly higher
mean levels of free testosterone. Specifically, we observed a significant association for
circulating free testosterone (OR for highest versus lowest tertile, 2.43; 95% CI, 1.15 to 5.10;
Ptrend = 0.03; Table 3).
We also observed a positive albeit nonsignificant association for circulating total
testosterone (OR for highest versus lowest tertile, 1.27; 95% CI, 0.62 to 2.61; Ptrend = 0.51).
Further, none of the other sex steroids evaluated showed significant associations with breast
cancer risk in this data set. We examined the effects of various confounders on these relative-
risk estimates by performing adjusted analyses. Relative-risk estimates remained virtually
unchanged after adjustments for BMI and education. We also evaluated potential variation in
the risk estimates for free testosterone by adjusting in different models for progesterone, total
testosterone, estradiol, and SHBG, and by excluding breast cancer cases diagnosed within 2
years after blood collection (n = 35), and all the risk estimates remained very similar (data not
shown).
Discussion
This study was designed to provide information on breast cancer risk in relation to
serum levels of sex hormones that markedly vary over the menstrual cycle. To reduce this
variability, blood samples were collected within a narrow window (days 20 to 24 of the
cycle) when most women were in midluteal phase. Then we adjusted our estimates for
variables related to ovarian-cycle time intervals and restricted the analyses to women with
regular cycles throughout their life.
Our findings are largely in line with those of previous reports, which have found few
consistent associations between sex steroids and breast cancer risk in premenopausal women,
with the exception of the consistent risk elevation associated with testosterone and free
testosterone. Of the prospective studies published to date [4-16], the two largest ones, based
in the European Prospective Investigation into Cancer and Nutrition (EPIC) and Nurses’
Health Study II (NHS2) cohorts, reported for circulating estradiol either no overall
association [4] or only if estradiol levels were measured in the follicular phase of the
menstrual cycle [11]. Our blood samples were collected exclusively in the luteal phase of the
menstrual cycle, and even though we accounted for the exact day within a woman’s
menstrual cycle at which blood was drawn, we did not observe an association between luteal
circulating estradiol and breast cancer risk in our analyses, which is in line with the findings
from the NHS cohorts [11]. For progesterone, previous reports were conflicting, reporting no
[11] or a significant inverse association [4] with breast cancer risk. Similarly, few and mostly
small prospective studies have explored the association between circulating testosterone and
premenopausal breast cancer risk. Both the European Prospective Investigation into Cancer
(EPIC) and Nurses’ Health Study (NHS) cohorts [4,11], the two largest studies to date, report
positive associations, particularly if testosterone was measured in the luteal phase [11]. We,
too, observed a significantly increased risk of breast cancer associated with higher circulating
levels of free testosterone. We did not observe an association between SHBG and breast
cancer risk in our study, which is also consistent with prior evidence [4,8,9,11,12].
Our study has several important strengths, relating to its prospective nature and
carefully timed sample collection, as well as information on important confounders. This
study is unique in that we were able to collect information on a women’s history of
menstrual-cycle irregularities throughout life, which allowed us subsequently to restrict it to
women with very consistent hormone profiles over their entire reproductive period. Our
results support that, in premenopausal women, it is imperative to apply a strict control of the
biologic variability of hormones and/or other biologic variables to test potential associations
with specific outcomes. In our sensitivity analyses, excluding cases diagnosed within 2 years
after blood collection, or in situ breast cancers, did not alter our findings.
Our study is limited by its relatively small sample size (even though it still ranks
among the larger studies published), which precluded more-detailed stratified analyses.
Whether a single blood measurement of sex steroid hormones, which fluctuate during the
menstrual cycle, sufficiently characterizes a premenopausal woman’s long-term hormone
levels is another concern. However, previous studies showed, particularly for androgens,
estrone sulfate, and to a lesser degree for estradiol and progesterone, that a single
measurement can reliably categorize average levels over at least a 3-year period in
premenopausal women [24]. Nonetheless, the necessity to better characterize and measure the
exposure to serum hormones called for a careful assessment of menstrual-cycle variability.
We excluded these women from our dataset, reducing sample size but substantially
improving our ability to detect associations that appear to become apparent only when
biologic variability is controlled for. In our analyses, no mathematical correction was made
for multiple comparisons. However, although such correction would have diminished
significance (for example, after Bonferroni correction, Ptrend < 0.01 would be considered
statistically significant, and none of our P values met this threshold), it does not appear to be
needed, given that we conducted only a few scientifically sensible comparisons.
Conclusions
Our findings suggest that premenopausal circulating testosterone, particularly free
testosterone, is associated with breast cancer risk when ovarian-cycle variability is carefully
controlled for. We also show that other sex steroids do not appear to play a major role in
developing premenopausal breast cancer. As evidence continues to accumulate for a positive
association between premenopausal circulating testosterone and breast cancer risk, potential
new preventive strategies should be designed and tested.